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Post-Transplant Lymphoproliferative Disorder (PTLD), Pediatric – Inpatient V 1.0

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Post-Transplant Lymphoproliferative Disorder (PTLD), Pediatric – Inpatient V 1.0 Provincial Clinical Knowledge Topic Post-transplant lymphoproliferative disorder (PTLD), Pediatric – Inpatient V 1.0 Copyright: © 2018, Alberta Health Services. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Disclaimer: This material is intended for use by clinicians only and is provided on an "as is", "where is" basis. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for the advice of a qualified health professional. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use. Revision History Version Date of Revision Description of Revision Revised By 1.0 December 2018 Topic Completed See Acknowledgements PTLD, Pediatric- Inpatient V 1.0 Page 2 of 25 Important Information Before you Begin The recommendations contained in this knowledge topic have been provincially adjudicated and are based on best practice and available evidence. Clinicians applying these recommendations should, in consultation with the patient, use independent medical judgment in the context of individual clinical circumstances to direct care. This knowledge topic will be reviewed periodically and updated as best practice evidence and practice change. The information in this topic strives to adhere to Institute for Safe Medication Practices (ISMP) safety standards and align with Quality and Safety initiatives and accreditation requirements such as the Required Organizational Practices. Some examples of these initiatives or groups are: Health Quality Council Alberta (HQCA), Choosing Wisely campaign, Safer Healthcare Now campaign etc. This topic is based on the following guideline(s): 1. Cincinnati Children's Hospital Medical Center 2008 (Updated 2011). Evidence Based Clinical Practice Guideline Management of EBV-Associated Post- Transplant Lymphoproliferative Disease (PTLD) in Solid Organ Transplant 2. National Comprehensive Cancer Network Clinical Practice Guideline in Oncology. Non- Hodgkin’s Lymphomas (2015) 3. Alberta Bone Marrow and Blood Cell Transplant Program: Standard Practice Manual PTLD, Pediatric- Inpatient V 1.0 Page 3 of 25 Rationale Post-transplant lymphoproliferative disorders (PTLD) are a heterogeneous group of lymphoid neoplasms associated with immunosuppression following solid organ transplantation (SOT) or allogeneic hematopoietic stem cell transplant (HSCT). The majority of PTLD following both allogeneic HSCT and SOT are of B-cell origin and are usually associated with Epstein Barr virus (EBV).3 Early PTLD are usually associated with concomitant detection of EBV DNA in blood samples in pediatrics, whereas late PTLD often present with no EBV DNA in blood.6 PTLD rates are reported to be higher in pediatric transplant recipients than in adult transplant recipients.7 The incidence of PTLD following allogeneic HSCT ranges from 1 to 3 %. The incidence of PTLD in children following SOT ranges from 1 to 20 % depending upon the type of organ transplant.8 After SOT, PTLD generally originates in cells that are recipient in origin, although it has been found to originate in donor cells after liver transplantation. Most frequently PTLD presents in the first year post transplant however it can also have late onset. The incidence of PTLD varies depending on several factors: type of organ transplant (e.g. highest risks in bowel, lung- heart/lung transplant), EBV serology mismatch (i.e. negative recipient/positive donor), cytomegalovirus (CMV) serology mismatch (i.e. negative recipient/positive donor), human leukocyte antigen (HLA) mismatch and anti-T-cell therapy (e.g. anti-thymocyte globulin [ATG] or anti-CD3 monoclonal antibody [OKT3]) for prevention or treatment of graft rejection, and for younger age.7-14 Reported rates are higher in heart, heart-lung, and small bowel transplants compared with kidney and liver transplants. This presumably reflects, in part, the need for more intense immunosuppression to maintain certain types of allografts. In terms of lymphoproliferative disease occurring within the allograft itself, this also depends on the type of graft. The lungs are frequently a site of involvement in patients undergoing heart-lung or heart- alone transplantation. Similarly, in small bowel transplants, the grafted bowel is commonly a site of PTLD. In cardiac transplants, the heart itself seldom is involved.9,11,15,16 In contrast to SOT, PTLD after HSCT is almost exclusively of donor origin and develops during the first 2 to 3 months after transplant. This unique feature is a consequence of the profound T- cell–depleting conditioning regimen, leading to lack of EBV-specific T-cells and, therefore, the often rapid growth of an EBV-positive clone, even within the first weeks.17 In patients post HSCT, factors associated with increased risk for PTLD include ex-vivo T-cell depletion of the allograft, unrelated or HLA-mismatched grafts, anti-T-cell therapy (e.g. antithymocyte globulin or anti-CD3 monoclonal antibody) for prophylaxis and treatment of graft-versus-host disease (GvHD), second transplant and immunocompromised recipient pre-transplant (i.e. Severe combined immunodeficiency [SCID]). Alemtuzumab is associated with low rates of PTLD (~2%), and this serotherapy is increasingly used as GVHD prophylaxis for non-malignant HSCT.16,18 The diagnosis and classification of PTLD can be challenging given the nonspecific clinical presentation and heterogeneity in histopathological and immunophenotypic presentations. There is now broad agreement that serial viral load monitoring is very helpful in defining the onset of primary EBV infection post transplantation (thus defining the patient as being at risk for PTLD), and in raising the suspicion of EBV disease/PTLD in the symptomatic patient. New- onset early PTLD in children is generally (though not universally) associated with very high peripheral blood EBV viral loads. Nevertheless, high EBV viral loads may occur in patients without symptoms at the time of primary infection, and in some patients, very high EBV viral PTLD, Pediatric- Inpatient V 1.0 Page 4 of 25 loads can persist for a long time. Thus high EBV viral loads are sensitive for the diagnosis of PTLD but not specific. In the 2008 WHO classification, PTLD are classified into 4 major categories: early lesions, polymorphic PTLD, monomorphic PTLD and classical Hodgkin Lymphoma (cHL) type PTLD.19 Note: Most recently the WHO 2016 is no longer using early lesions as part of the classification and has added three more categories instead: encompassing plasmacytic hyperplasia, infectious mononucleosis and florid follicular hyperplasia.20 Since most of the evidence is based on previous nomenclature, the previous classification will be used to provide recommendations.21 Table 1. WHO Classification of PTLD (2008) Category Description • Typically develop within a year of transplantation and are more common in transplant recipients who are EBV naïve. Early lesions • Show oligo- or polyclonal proliferations of EBV-positive B- cells while the underlying tissue architecture is preserved. • Consist of 2 histological subtypes: plasmacytic hyperplasia and infectious mononucleosis-like PTLD. • Demonstrate oligo- or polyclonal B-cell proliferations, the infiltrating cells destroy the original architecture of the host tissue. Polymorphic PTLD • While polymorphic PTLD can easily be differentiated from early lesions in lymph nodes, this can be very difficult in extranodal PTLD. • Histology appears to be the most common subtype and can resemble Non-Hodgkin Lymphomas in Monomorphic PTLD (B- and immunocompetent patients, usually originating from B- T-/NK-cell types) cell. • Most monomorphic type B cell PTLD are EBV positive whereas T-cell origin PTLD are usually EBV negative. Classical Hodgkin Lymphoma • HL-like PTLD resembles Hodgkin Lymphoma same as in (cHL) type PTLD an immunocompetent host. Source: Campo E, Swerdlow S, Harris N et al. The 2008 WHO classification of lymphoid neoplasms and beyond: evolving concepts and practical applications. Blood 117:5019-5032, 2011. It should be noted that exact classification in 1 of these 4 categories will not always be possible because of overlap between several categories or because PTLD can present as different morphologic subtypes within different locations in the body or even within a single biopsy sample. The latter finding is in concordance with the hypothesis that in some cases, there might be a progressive transition from early PTLD through polymorphic PTLD to monomorphic PTLD.22,23 PTLD, Pediatric- Inpatient V 1.0 Page 5 of 25 Table 2. Important Definitions A human being, living or deceased, who is a source of cells, Donor (D) tissues or organs for the purpose of transplantation.24 The human being into whom allogeneic human cells, tissues or Recipient (R) organs were transplanted.24 EBV viremia EBV DNA detectible in blood by PCR analysis.25 EBV detected (nucleic acid or serologically) in an EBV- Primary EBV infection seronegative patient. 25 Detection of EBV DNA in the blood in an EBV-seropositive Recurrent EBV infection patient.25 Any agent given to EBV-seropositive patient to prevent
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